The ravings of a capacity building fundamentalist

Last week every suggestion Gary & I made (well all two of them, allocated patients & weekly ward training sessions/meetings) at the ITU medicine ward meeting were declared “impossible” by a militant & united mass of nurses and doctors. But today in the hospital morning meeting, the chief of surgery, an orthopaedic surgeon with a killer smile, flashed me that smile then winked at me (swoon). Then the gynaecologist to my left implored me to speak up more in these meetings, he wanted my support. The ups & downs in this volunteering lark are giving me motion sickness.

The morning meeting was discussing the case of an 82 year old man who had fallen out of bed and died (not an unfamiliar scenario in an NHS hospital) but no-one would speak up to suggest that perhaps the hospital was responsible for looking after patients when they are in its care. The Gynaecologist - a Cambodian doctor who has spent 3 years in France training – wouldn’t speak up with his opinion because he said they would all just get angry with him & then say he thought he was better than them. I countered this with my tested truth that if I said something I would also get anger & then be told that this is Cambodia and I am NOT Cambodian.

Sometimes I feel that certain members of the hospital staff do want me there (not just because they are winking at me), they are just not sure what to do with me. Often they just want me to be their voice – I have Barang immunity – to say the difficult stuff that they all know but are trapped in silence by Cambodian cultural norms. They also say that they want my expertise but when I question their practice or suggest even small changes the heels dig in & the “this is Cambodia” speech is trawled out.

The ITU medicine ward’s agenda currently is for Gary & I to support them to have ventilated patients on the ward & show them how to use the new shiny defibrillators that a French doctor donated. Gary & my agenda differs slightly – we would like to implement ward management, improve basic nursing care & improve doctors’ clinical reasoning skills & management of patients. Basically using child development milestones, we want them to sit unsupported, they want to hop, skip & jump.

This weekend I went to Siem Reap with Katie & her brother, who was out visiting. We found ourselves tricked into going to a free ‘concert’ which was in fact a fund raising event for one of the NGO hospitals there.

Whenever I try to promote continuing medical education (CME) & regular training & supervision sessions with the hospital staff, the second most common response is “we are not an NGO hospital, that won’t work here” (the first is the “this is Cambodia” chestnut). It frustrates me but after sitting through the pseudo-concert I found myself beginning to understand the thinking of my Cambodian counter parts – astonished that cleaners at the NGO hospital earn $250 a month whilst a Government Hospital doctor earns $100, nurses $70. If the doctors & nurses aren’t on the wards you will find them in their private clinics or working their 2^nd & 3^rd jobs to earn a living wage.

I’m not suggesting that NGO hospitals aren’t doing a fantastic job and providing essential care to the sickest and poorest, its just they are not always helping to improve the government health system in the process. In fact they may well be making matters worse because despite what the cello playing Swiss doctor tells all the tourists so ready to part with their US$ for a good cause – it is not sustainable to run a hospital where 90% of its running relies on private donations. There is nothing sustainable about creating inequalities in workers salaries & training and care provided to patients. It is an admirable life’s work & has filled a huge short fall in health care services in a post war Cambodia – but surely what Cambodia needs now is to work towards providing good healthcare to all Cambodians and stop being so reliant on outsiders’ money & skills.

Angkor Hospital for Children is another NGO hospital in Siem Reap - I've worked with some of their doctors because they collaborate with other NGOs in health, they run training programmes from their hospital, they accept referrals from government hospitals and their doctors work in government hospitals to improve child health in Cambodia.

Nothing would give me greater pleasure than to rearrange the ward to how Gary & I want to run it, to see my own patients, make clinical decisions & feel as if I was actively doing something to improve patients’ wellbeing & health. But (and it’s a big but) that is not why I am here, it is not why I chose to go away with VSO, its not what capacity building is about. So when Dr L tries to get me to do an LP when Dr R had failed to be successful  (mainly as he was attempting to do an LP through the sacrum by the look of the puncture mark position) I say no. However I encourage Dr L to perform it, film him for training purposes and then persuade Dr L to supervise Dr R for the next LP. Dr L is the LP king and I tell him that, it makes a nice change from my usual 3 year-old-like "why" constant questioning of him plus I don't want to humiliate myself in front of him, he does an LP in the time I will have injected the local anaesthetic. Although I do have emergency medic footage of me putting in a chest drain if he ever doubts my clinical skills!

Back to the pseudo-concert - I was also puzzled by the assertion from the speaker that poor people don’t die of poverty, his proof was that nearly all the children treated at his hospital survive & never get sick again (at this point I nearly walked out). Living on less than a dollar a day, no sanitation, no clean water, little nutrition, no money for schooling, no transport to access health care, lack of empowerment, corruption and poor governance do affect your health – I wanted to shout – but instead I chewed my hand off. I suffered the next day for that illicit nail chewing - all kinds of unsavory e.coli were hanging out there it would seem. However I was able to spend the 3 hours on the toilet reading a very good book - Half the Sky - a study on the struggle for equality for women within an international development context (check it out). I find myself growing more cynical by the day about international development so a few uplifting stories helps.

The other day in a particularly dull meeting with no translation I re-read an essay I’d written for my Child Health MSc, on international health policy. The naivety of my academic writing made me smile. Forgive me while I quote myself, the title was - What characterises the policy and organisational developments in those developing states that have achieved progress on public health?

“Conclusion

Although there is agreement that better public health policies improve population’s health, the evidence base for policy outcomes and cost-effectiveness is weak. Progress in achieving the Millennium Development Goals continues to be constrained by a lack of knowledge of how best to reform health systems. Further research is required as presently much of what is known to be effective is on a case study basis, the scope for transferable learning is great.

There is a tendency for cost-effectiveness of health care to dominate in policy making, as there is a constant political pressure to deliver immediate results. This has to be countered with capacity building of systems which can be time consuming and initially quite costly before long term gains are recognised. 

Context is essential when formulating policies and organisational developments that will be effective in improving public health. Generally speaking policies that are integrated into the macro-economic framework and health-in-all policies have a greater impact on public health. 

Reforming and financing health needs to be in line with the ideology of a population and failure to address this will impact on the progress in public health. A “bottom-up” approach with local community participation and clearer accountability has been shown to improve delivery of universal health-care and the equity of resource allocation. This however is dependent on a strong central government free from internal corruption or ‘bullying’ from international actors to instigate healthy policies that will be sustainable, empower the vulnerable groups within that society and result in better health for all.

“The Public health disasters of failed states provide ample evidence that a strengthened state is a necessary condition.” "

I’m not even sure I really understood the extent that corruption impacts on health or the complexities of NGOs and international health politics when I wrote this, but I had read a lot about it. Now I’m living it and could do with some practical solutions, I'm not sure there are any definitive answers.

But for the time being I'm going to corner the winking surgeon to see if he'd like to go on a primary trauma care course in Siem Reap to become an instructor, safe in the knowledge that I may not have a CT or MRI scanner but I do have a strong belief in capacity building even if it is costly & time consuming & I won't get to see any of the long term gains.

On the subject of definitive answers, I think we can conclude to the question "what is the appropriate foot wear when visiting Angkor Wat?" the definitive answer is "NOT flip flops". If only development work was as straight forward!